Cardiology Flashcards
What score will calculate percentage risk patient with have a stroke or myocardial infarction in the next 10 years?
Q-risk
if Q-risk is above 10% what should you offer
- statin
- current guidelines are atorvastatin 20mg at night
all patients with chronic kidney disease or T1DM for more than 10 years should be offered:
atorvastatin 20mg
Secondary prevention of cardiovascular disease consists of what 4 things:
the 4As
A-aspirin (+second antiplatelet for 12 months)
A-atorvastatin 80mg
A-atenolol (beta blocker, bisoprolol)
A-ace inhibitor (rampiril)
3 notable side effects of statins
- myopathy
- T2MD
- haemorrhagic stroke (rare)
stable angina is..
constricting chest pain when symptoms are relieved by rest or glycerl trinirtrate (GTN spray)
unstable angina is…
constricting chest pain that comes on randomly at rest.
gold standard for diagnostic investigation of angina
- CT coronary angiography
- injecting contrast and taking CT images timed with heart beat
- highlights any narrowing of the coronary arteries
summarise all baseline investigations for patients with suspected angina
- physical exam (heart sounds, signs of HF, BMI)
- ECG
- FBC (anaemia)
- U&Es (prior to ACEi & other meds)
- LFTs (prior to statins)
- lipid profile
- thyroid function tests
- HbA1C and fasting glucose (diabetes)
four principles to management of angina according to 2018 NICE guidelines
R- refer to cardiology
A - advice them about diagnosis, management, when to call and ambulance
M- medical treatment
P - procedural management
describe immediate symptomatic relief of angina
- GTN spray
- causes vasodilation
- use it, repeat after 5 minutes, if there is still pain 5 mins after repeat dose the call for an ambulance
describe long term symptomatic relief of angina
FIRST LINE
- beta blocker (bisoprolol 5mg once daily)
- calcium channel blocker (e.g. amlodipine 5mg once daily)
other options
- long acting nitrates (isosorbide mononitrate)
- ivabradine
- nicorandil
- ranolazine
what two procedural / surgical interventions are available for angina relief?
- percutaneous coronary intervention with coronary angioplasty (PCI)
- coronary artery bypass graft (CABG)
how does percutaneous coronary intervention work?
- dilating blood vessel with balloon and or inserting a stent
- catheter into brachial or femoral artery, feeding it to coronaries under X-ray guidance
what surgery may be offered to patients with severe stenosis?
coronary artery bypass graft
- involves opening chest (midline sternotomy scar) and taking a graft vein from patients leg (usually great saphenous))
- this is then sewn on to affected coronary artery to bypass stenosis
acute STEMI treatment
within 12 hrs onset
- primary PCI (if available within 2hrs of presentation)
- thrombolysis (if PCT not available within 2 hours)
what does thrombolysis involve?
- fibrinolytic medication
- streptokinase, alteplase, tenecteplase
acute NSTEMI treatment
B - beta blockers
A - aspirn 300mg stat
T - Ticagrelor 180mg stat (clopidogrel 300mg alternative)
M - morphine
A - anticoagulant (LMWH, enoxaparin)
N - nitrates (e.g. GTN spray)
complications of MI
D - death
R - rupture of heart septum or papillary muscles
E - oedema
A - arrhythmia and aneurysm
D - dressler’s syndrome
what is Dressler’s syndrome?
- occurs 2-3 weeks post MI
- caused pericarditis
- caused by localised immune response
Dressler’s syndrome presents with
- pleuritic chest pain
- low grade fever
- pericardial rub on auscultation
- can cause pericardial effusion
diagnosis of dressler’s syndrome made via
- ECG (global ST elevation and T wave inversion)
- ECHO
- raised inflammatory markers (CRP and ESR)
management of Dressler’s syndrome
- NSAIDs (aspirin, ibuprofen)
- more severe cases may require steroids such as prednisolone
- may require pericardiocentesis to remove fluid from around the heart
secondary prevention medical management of MI
- aspirin 75mg OD
- another antiplatelet (clopidogrel or ticagrelor for up to twelve months)
- atorvastatin 80mg OD
- ACEi (rampiril)
- atenolol (BB)
- aldosterone antagonist (if clinical heart failure)
what is acute left ventricular failure?
- LV unable to efficiently move blood to LHS of body
- causes backlog of blood
- increased blood in LA, pulmonary veins and lungs
- vessels engorge with blood then leak, unable to reabsorb fluid from surrounding tissues
- pulmonary oedema
- alveoli become filled with interstitial fluid
presentation of acute left ventricular failure
- rapid onset breathlessness
- exacerbated by lying flat
- improves on sitting up
- acute LVF caused T1RF
- cough (frothy white / pink sputum)
type 1 respiratory failure
low oxygen without an increase in carbon dioxide in the blood
on examination with patient with acute left ventricular failure:
- increased RR
- reduced sats
- t.cardia
- 3rd heart sound
- bibasal crackels (wet on auscultation)
- hypotension (severe, cardiogenic shock)
- cardiomegaly?
- upper lobe venous diversion
fluid leaking from oedematous lung tissue causes additional XRAY finding of:
- bilateral pleural effusions
- fluid in interlobar fissures
- fluid in the septal lines (kerley lines)
action of BNP
- relax smooth muscle in blood vessels
management of acute left ventricular failure
Pour SOD
- Pour away IV fluids
- sit upright
- oxygen
- diuretics (e.g. IV furosemide 40mg stat)
- monitor fluid balance
key features a patient with chronic heart failure may present with:
- breathlessness worse by exertion
- cough (frothy pink / white sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea
- peripheral oedema
first line medical treatment for chronic heart failure
- ACE Inhibitor (e.g. rampiril)
- Beta blocker (bisoprolol)
- aldosterone antagonist (when symptoms not well controlled with A+B)
- loop diruetic imrpove symptoms (furosemide)
Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with an…
ACEi
Beta blocker
What is Cor pulmonale?
RHS heart failure
caused by respiratory disease
pulmonary hypertension
signs of cor pulmonale
- hypoxic
- cyanosis
- raised JVP
- peripheral oedema
- third heart sound
- murmur
- hepatomegaly
management of cor pulmonale
- treating symptoms and underlying cause
- long term oxygen therapy often used
NICE guidelines on hypertension from 2019 suggest a diagnosis of hypertension with a blood pressure above
140/90 in clinic or 135/85 with ambulatory or home readings.
secondary causes of hypertension
ROPE
R- renal disease (renal artery stenosis)
O- obesity
P- pregnancy induced hypertension / pre-eclampsia
E-endocrine (consider hyperaldosteronism)
clinical reading of stage 1 hypertension
> 140/90
clinical reading of stage 2 hypertension
> 160/100
or
>150/95 ambulatory home reading
clinical reading of stage 3 hypertension
> 180/120
What investigations should all patients with a new diagnosis of hypertension undergo?
- urine albumin:creatinine ratio (proteinuria and dipstick for microscopic haemturia to assess for kidney damage)
- bloods, HBA1C, renal function, lipids
- fundus examination, hypertensive retinopathy
- ECG for cardiac abnormalities
Medications for hypertension
A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily)
B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily)
C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily)
D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)
ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily)
what is used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent?
angiotensin receptor blocker
initial management of hypertension diagnosis
- establish diagnosis
- investigate possible causes and end organ damage
- lifestyle advice
Step 1 hypertension medical management
Step 1: Aged less than 55 and non-black use ACE inhibitor
Aged over 55 or black of African or African-Caribbean descent use Calcium channel blocker.
Step 2 medical management of hypertension
Step 2: A + C. Alternatively A + D or C + D.
If black then use an ARB instead of A.
Step 3 medical management of hypertension
A + C + D
ACEi, BBm Thiazide like diuretic
Step 4 medical management of hypertension
Step 4: A + C + D +
if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone.
If the serum potassium is more than 4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol).
treatment targets for hypertension
UNDER 80 years of age
- < 140/ <90
OVER 80
- < 150/ <90
first heart sound caused by
- closing of atrioventricular valves (tricuspid and mitral valves)
second heart sound caused by:
- closing of semi lunar valves (pulmonary and aortic valves)
3rd heart sound is heard how roughly how many second post second heart sound
0.1 second
what causes third heart sound?
- rapid ventricular filling
- causes chordae tendinea to pull to their full length
- normal aged 15-40
- older can suggest HF
when is fourth heart sound heard?
directly before S1
is fourth heart sound every normal?
- always abnormal
what would fourth heart sound indicate?>
- stiff or hypertrophic ventricle
- caused by turbulent flow from atria contracting against non-compliant ventricle
which manouver emphasises mitral stenosis?
patient lying on their left side
which manouver emphasises aortic regurg?
patient sat up, leaning forward and holding exhalation
assessing murmur
SCRIPT
S- site C- character: soft blowing, crescendo, decrescendo R- radiation (carotids, left axilla) I- intensity P-pitch T-timing
Grading murmurs
- Difficult to hear
- Quiet
- Easy to hear
- Easy to hear with a palpable thrill
- Can hear with stethoscope barely touching chest
- Can hear with stethoscope off the chest
mitral stenosis causes what type of hypertrophy
left atrial hypertrophy
aortic stenosis causes what type of hypertrophy
left ventricular hypertrophy
mitral regurgitation causes what kind of dilatation
left atrial dilatation
aortic regurgitation causes what kind of dilatation
left ventricular dilatation
two causes of mitral stenosis
- rheumatic heart disease
2. infective endocarditis
what type of murmur does mitral stenosis cause?
mid diastolic, low pitched
rumbling due to low velocity of blood flow
loud S1: thickening of valves requiring large systolic force to shut
mitral stenosis is associate with:
- malar flush
2. AF
mitral regurgitation results in:
congestive cardiac failure
leaking valve causes reduced ejection fraction and backlog of blood
what kind of murmur does mitral regurgitation cause:
- pan-systolic, high pitched
- whistling murmur due to high velocity blood flow through leaky valve
- murmur radiates to axilla
name two connective tissue diseases which may cause mitral regurgitation
- Ehlers Danlos syndrome
- Marfan syndrome
aortic stenosis murmur
- ejection systolic, high pitched murmur
- crescendo-descredno character due to speed of blood flow across valve
what symptoms may patient with aortic stenosis complain of:
Extertional syncope
due to difficulty maintaining good flow of blood to brain
aortic regurgitation causes what type of murmur
- early diastolic, soft murmur
aortic regurgitation is associated with
collapsing pulse
apidly appearing and disappearing pulse at carotid as the blood is pumped out by the ventricles and then immediately flows back through the aortic valve back into the ventricles.
Austin-Flint murmur
- heard at apex
- an early disatolic rumbling murmur
biprosthetic valves lifespan
10 years
mechanical valves lifespan
over 20 years
although require lifelong anticoagulatoin with warfarin
major complications of mechanical heart valves (3)
- thrombus
- infective endocarditis
- haemolysis
what treatment is transcatheter aortic valve implantation for?
severe aortic stenosis
catheter - femoral artery - x-ray guidance, balloon to stretch stenosed aortic valve
infective endocarditis is usually caused by:
gram positive cocci
- staphylococcus
- streptococcus
- enterococcus
ECG finding in AF
absence of P waves
narrow QRS complex tachycardia
irregularly irregular ventricular rhythm
Most common causes of AF
SMITH
SEPSIS
MITRAL VALVE PATHOLOGY (STENOSIS OR REGURG)
IHD
Thryotoxicosis
Hypertension
two principles for treating AF are rate or rhythm control
describe options for rate control
- beta blocker
- calcium channel blocker (diltiazem)
- digoxin
two principles for treating AF are rate or rhythm control
describe options for rhythm control
Electrical cardioversion
pharmacological cardioversion
- amiodarone
- flecanide
long term medical rhythm control :
- bb first line
- dronedarone second line where patient shave had successful cardioversion
- amiodarone in patients with HF or left ventricular dysfunction
Paroxysmal Atrial Fibrillation
comes and goes in episodes not lasting more than 48hrs.
- flecanide
when should flecanide be avoided?
- in atrial flutter
- can cause 1:1 AV conduction, resulting in significant t.cardia
INR is a calculation of:
- how the prothrombin time of patient compares with prothrombin time of a normal healthy adult
INR is also affected by many foods such as …
- ones that contain vit K such as leafy greens
cranberry juice and alcohol affected P450
